Feature

It’s about saying the right thing

Is it safe for staff to say what they think about working in the NHS? Peter Bruggen has listened to many tales of despair, and offers some straightforward advice

Dear Stakeholders in the NHS

I first heard the nickname ‘Ministry of Truth’ for the NHS Executive on one a day I walked around Quarry House in Leeds. I had passed the doors of the Department of Intelligence, so the Ministry of Truth seemed a particularly good title for the executive brain of the NHS reforms.

Shortly before this year’s general election, the Department of Intelligence was closed. Its job was to help trusts and health authorities get the message of the reforms across. What a contrast to the run-up to the previous election. Then, all efforts were made to rush things through, strengthen existing changes and even offer ministers ‘departmental’ briefings before party political meetings. At that time there was a determination within the department that no new Labour government would be able to unscramble the reforms.

Were they right to relax this time around? Are the reforms safe with Labour? Maybe they will be (and maybe you don’t want the reforms themselves to be safe). But I am trying to write about you: are you safe?

I don’t want to be alarmist, but there are things you ought to know. The first is that you are not alone. I interviewed, on average, four contributors for each of the 25 chapters in my book Who Cares?. Fairly soon I realised the same themes ran through most of their stories. Even in the strange story of the ‘phone tap’, the goings-on in that hospital were not unique.

So, whatever you have experienced, there will probably be someone else who has been through something similar. If in doubt, try me. (My email address is in the front of the book.)

The Nolan Proposals

You will have heard of people being treated badly, or seeing others being treated badly. For instance, when staff find out that arrangements are turning out differently from what they believe had been promised and say so. And then all they get from the manager is: ‘Is that what you heard me say?’ and a cold shoulder. Or an internal enquiry into a tragedy is handled with great insensitivity and staff appear to be bullied in the hunt for scapegoats, but any protest is greeted with the response that ‘the difficulties are local and that the board is totally behind the manager concerned’. Or managers say that certain changes must be made because the purchaser wants them, but the purchasers deny saying any such thing.

Well, the Nolan Report had a suggestion to make (see box). You may not have known that the Committee on Standards in Public Life devoted much of its first report to the NHS but just two of its simplest proposals could have made such a difference to many circumstances.

I do not know if any trust has seriously implemented these proposals. But they are in the interests of trust boards, and would safeguard the executive directors and the chairmen. It might even be safer for patients.

One of the things that troubles me is that I don’t know if it is wise for you to ask.

Banning the silent clauses could also be done easily, but this has direct bearing on fewer people. Although the number of cases in any one place is few, they do have quite an effect. Do you remember anyone leaving at a few hours’ notice? ‘So and so no longer works for the trust’ or ‘Three hours to clear your desk’. I was often told that the silence rule safeguarded the person in question, but I never supposed that many people would actively seek to broadcast damaging information about themselves. So who was really being protected?

I found it strange to be leaving one of my contributors, after a pleasant chat about the NHS, not one jot wiser about the story I was writing up.

The Patient’s Charter

I thought there was quite a lot of good in the charter, although it did give management a lot of staff photographs to show to the police or people making complaints.

The boasts about the information available to patients made me want to say, ‘What about the staff?’ They need information too, often about themselves; and they have a role in giving information to patients (or not giving it, if that is the order). Let me illustrate.

If you have a somewhat difficult meeting with your manager, has it ever occurred to you that he or she may have typed a report afterwards? This is not a formal document, with minutes, which you can access, but a typed note you are unaware of. Now I am not suggesting you ask, but you might like to know. Margaret (who first told me of this practice) decided to do nothing when such a report was spotted in the office, but she felt wiser.

Cover up, being part of

Patients have more information than ever before, says the charter. Yes, up to a point. But where the reforms lead to sudden changes (especially operation cancellations) staff may be instructed not to inform patients and relatives fully. (I give an account of this in the chapter on bureaucracy and report the care with which the instruction to dissemble was given verbally, but still unambiguously.)

One specialist unit had obviously been having some difficulty in smoothing over the complications of contracts, active and non-active, ECRs, purchasers and providers. Its new brochure boasted that the patient should not even be aware of this particular expenditure of public money.

How often have you been ‘made’ to take part in a conspiracy of silence or misinformation?

What will happen now?

In my researches I discovered the most worrying unwritten rule, the breaking of which could lead to the sack. It was: ‘Do not answer the minister’s questions’. You will know that there are 101 ways of saying ‘All is well’ when asked how you are finding the changes. And you will know that that is the way to get on in the reforms. I came across several very senior managers who often met health ministers at the height of the reforms. Sometimes the ministers were insistent in their questioning: what was it really like in such and such an area, or with such and such a reform? They would not be satisfied with ‘It’s very exciting’ and ‘A wonderful challenge’. Under such pressure and with the reassurance that the minister really did want to know, a few answered truthfully. They lost their jobs.

healthmatters has given the new government good marks so far for caution. On the whole I support this. The last thing the exhausted NHS troops need is a new Duke of York taking them up and down a different hill.

But the next round of management cuts? Will it be any different to last time? Again, I heard several stories of management cuts leading to a mini re-organisation, with those in peril scrambling for jobs. The favoured strategy was: first, welcome the reduction and the proposed restructuring; second, write memos, papers and proposals of how to further the aims of the department or trust within it; and third, give detailed statistical backing, while couching conclusions fully in the latest government or management speak. The details and statistics were easily arrived at by bullying underlings, similarly startled into fear for their jobs. Thus, hitherto dedicated and honourable managers, disillusioned by the way the government, or NHS Executive, had treated them, found themselves treating their subordinates in exactly the same manner. And when it was all over, nobody left bothered to check the validity of the statistics or other details of the papers that had earned successful candidates their jobs. They were into the next round of crisis management.

So when you feel the effects of all this as it starts to happen again, spare them a thought, and remember the Ministry of Truth.

Can you make it any different? I don’t know.

Yours sincerely

Peter Bruggen